Manipulation Under Anesthesia Research Articles

Total knee arthroplasty in post-traumatic osteoarthritis is more challenging, but results in similar patient satisfaction – An analysis of 1646 cases

BackgroundPatients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA). MethodsA registry-embedded prospective case–control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively. ResultsSurgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts. ConclusionsThis study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.

The Effect of Manipulation Under Anesthesia for Secondary Frozen Shoulder: A Randomized Controlled Trial.

Manipulation under anesthesia (MUA) is often used for frozen shoulder treatment, but controversy still exists regarding MUA compared with conservative treatment. This research was conducted to compare the outcome between MUA and celecoxib (CLX) in secondary frozen shoulder. Patients with secondary frozen shoulder were randomized into two groups, an MUA plus exercise (EX) group and a CLX plus EX group. Clinical outcomes were documented at baseline and at 1day, 2, 4, and 12weeks after intervention, including Constant-MurleyScore (CMS) for function, Pain Rating Index (PRI) and Present Pain Intensity (PPI) for pain, passive range of motion (ROM) measurements including external rotation, internal rotation, forward flexion, and abduction. Primary outcome was CMS. Secondary outcomes were PRI, PPI, and passive ROM. Sixty-seven patients out of 68 in the MUA group and 66 out of 68 in the CLX group finished the entire study period. There were no significant differences in basic properties of the two groups before intervention. As the primary outcome, CMS changes in the MUA group improved faster than the CLX group. Secondary outcomes, passive ROM, and pain PPI were faster and significant in the MUA group from 1day after intervention compared with CLX (P < 0.05). At 12weeks, a statistically significant difference was not observed in the PPI (P > 0.05). A statistically significant difference was not observed in the PRI between groups in 1day (P > 0.05). For the primary outcome, from 0 to 12weeks the mean changes in CMS were 44.00 for MUA plus EX (95%CI 43.07-44.93, P < 0.001) and 27.09 for CLX plus EX (26.20-27.98, P < 0.001). The significant difference in improvement appeared from 2weeks. To treat secondary frozen shoulder with MUA, this treatment could achieve better therapeutic effects on improvement of function, pain, and passive ROM than CLX did. The trial was registered at www.chictr.org.cn , identifier ChiCTR2200060269.

Understanding rates, risk factors, and complications associated with manipulation under anesthesia after total knee arthroplasty (TKA): An analysis of 100,613 TKAs

BackgroundConsidering the growing adoption of technology-assisted total knee arthroplasties (TKA), previous database studies evaluating post-operative stiffness may be outdated. The present study aimed to: (1) evaluate the incidence of manipulation under anesthesia (MUA) after primary TKA; (2) determine independent risk factors for MUA; and (3) assess complications after MUA. MethodsPrimary TKAs, with at least 6-month follow-up, were identified from the Florida State Inpatient Database (January 2016–June 2018) and linked to outpatient records from the Florida State Ambulatory Surgery and Services Database. Multivariable regression analyses were performed to compare patient factors and complications (e.g., mechanical, non-mechanical, infectious) associated with MUA, while adjusting for baseline demographics, comorbidities, use of robotic- and computer-technologies, time to MUA (0–3, 3–12, or >12 months), and need for repeat MUA (one-time vs >1). ResultsThe MUA rate was 2.8% (2821 of 100,613). Being younger, a woman, Black or Hispanic; having private or self-pay insurance; and conventional TKA were associated with significantly higher odds of undergoing MUA. Higher rates of mechanical complications and acute posthemorrhagic anemia were observed in the MUA cohort. Time to MUA, repeat MUA, and baseline demographics were not associated with complication rates among the MUA cohort. ConclusionOverall, 1 in 36 patients underwent MUA after primary TKA. Several non-modifiable patient characteristics, such as Black or Hispanic race, female sex, and younger age were associated with an increased risk of MUA. However, technology-assisted TKA might help to decrease the risk of MUA.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study.

Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures. From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n =44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis. Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD. Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.

Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review.

Background:Postoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA).Purpose:To review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes.Study Design:Systematic review; Level of evidence, 4.Methods:This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded.Results:Eight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention.Conclusion:The results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.

Early manipulation under anaesthesia for stiffness following total knee arthroplasty is associated with a greater gain in knee flexion

PurposeThis study aimed to identify the risk factors for manipulation under anaesthesia (MUA) following total knee arthroplasty (TKA) and whether performing an ‘early’ MUA within 3 months leads to a greater improvement in range of motion.MethodsPrimary TKAs performed between 2013 and 2018 at three tertiary New Zealand hospitals were reviewed with a minimum follow-up of 1 year. Clinical details of patients who underwent MUA were reviewed to identify the knee flexion angle prior to and following MUA. Multivariate analysis identified the risk factors for undergoing MUA and compared flexion angles between ‘early’ (< 3 months) and ‘late’ MUA (> 3 months).ResultsA total of 7386 primary TKAs were analysed in which 131 underwent an MUA (1.8%). Patients aged < 65 years were two times more likely to undergo MUA compared to patients aged ≥ 65 years (2.5 versus 1.3%, p < 0.001; adjusted HR = 2.1, p < 0.001). There was no difference in the final flexion angle post-MUA between early and late MUA (104.7° versus 104.1°, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3° versus 79.6°, p = 0.012), and subsequently had a greater overall gain in flexion compared to those who underwent late MUA (mean gain 33.1° versus 24.3°, p < 0.001).ConclusionYounger age was the only patient risk factor for MUA. Patients who underwent early MUA had similar post-MUA flexion, but had poorer pre-MUA flexion compared to those who underwent late MUA. Subsequently, a greater overall gain in flexion was achieved in those who underwent early MUA.Level of evidenceIII.

Manipulation Under Anesthesia is Safe After Cementless Total Knee Arthroplasty: A Multicenter Study

BackgroundCementless total knee arthroplasty (TKA) is thought to facilitate durable, biological fixation between the bone and implant. However, the 4-12 weeks required for osseointegration coincides with the optimal timeframe to perform a manipulation under anesthesia (MUA) if a patient develops postoperative stiffness. This study aims to determine the impact of early MUA on cementless fixation by comparing functional outcomes and survivorship of cementless and cemented TKAs. MethodsA consecutive series of patients who underwent MUA for postoperative stiffness within 90 days of primary, unilateral TKA at 2 academic institutions between 2014 and 2018 were identified. Cases involving extensive hardware removal were excluded. Cementless TKAs undergoing MUA (n = 100) were propensity matched 1:1 to cemented TKAs undergoing MUA (n = 100) using age, gender, body mass index, and year of surgery. Both groups had comparable baseline Knee Injury and Osteoarthritis Outcome Scores (KOOS), Short Form (SF)-12 Physical, and SF-12 Mental scores. MUA-related complications as well as postoperative KOOS and SF-12 scores were compared. ResultsMUA-related complications were equivalently low in both groups (P = .324), with only 1 patella component dissociation in the cementless group. No tibial or femoral components acutely loosened in the perioperative period. Postoperative KOOS (P = .101) and SF-12 Mental scores (P = .380) were similar between groups. Six-year survivorship free from any revision after MUA was 98.0% in both groups (P = 1.000). ConclusionEarly postoperative MUA after cementless TKA was not associated with increased MUA-related complications or worse patient-reported outcomes compared to cemented TKA. Short-term survivorship was also comparable, suggesting high durability of the bone-implant interface.

Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes.

To compare failure rates and outcomes after transosseous equivalent (TOE) double row (DR) knotted suture bridge versus knotless suture tape bridge repair techniques for rotator cuff tears. A consecutive series of 272 shoulders in 256 patients who underwent arthroscopic, double row, TOE repair for full-thickness tears of the supraspinatus tendon were reviewed. Eighty-four shoulders were repaired using knotted suture bridge (KSB) technique, and 188 shoulders were repaired using all knotless suture tape bridge (KTB) technique. Revision procedures and concomitant subscapularis tendon repairs were excluded from analysis. The minimum follow-up was 12months. Primary outcome was failure of surgical repair, defined as either confirmed retear on MRI and/or need for revision surgery. Secondary clinical outcome measures were assessed including range of motion, strength, visual analog scale (VAS), operative time, subjective shoulder value (SSV), Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Brophy shoulder activity scores, and need for manipulation under anesthesia (MUA). A total of 127 shoulders (38 KSB and 89 KTB) met inclusion criteria for the study. No significant difference in demographic variables were present between the groups at baseline. Supraspinatus tear size and average follow-up time did not differ significantly between groups. Failure rates were similar between the KSB and KTB repairs (13.1 vs 7.9%, n.s.). There was no significant difference in functional outcomes including strength, range of motion in forward flexion and external rotation, as well as patient reported outcomes including VAS, SSV, PROMIS, ASES, and Brophy scores between the groups. There was also no difference in post-operative stiffness requiring MUA. Both KSB and KTB repair techniques demonstrate low retear rates with excellent functional outcomes when compared to pre-operative examination. Both KSB and KTB techniques are viable options for achieving a successful rotator cuff repair. Level III.

Manipulation under Anesthesia versus Non-Surgical Treatment for Patients with Frozen Shoulder Contracture Syndrome: A Systematic Review.

Purpose: To investigate the efficacy of manipulation under anesthesia (MUA) compared to other non-surgical therapeutic strategies for patients with frozen shoulder contracture syndrome (FSCS). Methods: A systematic review of literature was conducted. A literature search was performed in MEDLINE, EMBASE, PEDro, Cochrane Central Library and Scopus. Only randomized controlled trials were included and assessed for critical appraisal through the Cochrane Collaborations tools. Results: Five randomized controlled trials were included. The overall risk of bias (RoB) was high in 4 out of 5 of the included studies. MUA was found to be not superior in terms of reduction of pain and improvement of function when compared to cortisone injections with hydrodilatation (mean regression coefficient MUA −2.77 vs. injection −2.75; 95% CI (−1.11 to 1.15)) and home exercise (mean difference 95% CI: 0.2 (−0.64 to 1.02)) in the short term (3 months), and cortisone injections with hydrodilatation (mean regression coefficient MUA 3.13 vs. injection 3.23; 95% CI (−0.90 to 1.11)) in the long term (>6 months). Moreover, if compared to structured physiotherapy, MUA highlighted a higher Oxford Shoulder Score at final 1-year follow up (mean difference 95% CI: 1.05 (−1.28 to 3.39); p = 0.38). Similar results were obtained for disability, with statistically no significant long-term (>12 months) differences between MUA and home exercise (mean difference 95% CI: 0 (−3.2 to 3.2)) or structured physiotherapy (mean difference 95% CI: −0.50 (−5.70 to 4.70); p = 0.85)). Only two trials reported adverse events. Conclusions: This review suggested that limited and inconsistent evidence currently exists on the efficacy of MUA compared to other non-surgical strategies in the management of patients with FSCS. Future research should focus on clinical trials with higher methodological quality.

The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty.

Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.

Poster 152: Arthroscopic Bankart Repair Following a Second Dislocation Results in Increased Failure Rates Compared to Immediate Repair After Following a Traumatic First Time Dislocation

Objectives:Many surgeons will consider nonoperative treatment following a 1st time dislocation and will consider operative management if a second instability event occurs particularly for the in season athlete. The objective of this study was to compare rates of recurrent dislocation and post-surgical outcomes in patients undergoing arthroscopic bankart repair for anterior shoulder instability immediately following a 1st time traumatic anterior dislocation versus patients who sustained a 2nd dislocation event following initial conservative management. We hypothesized that patients sustaining a 2nd anterior shoulder dislocation would be more at risk for recurrent dislocations after arthroscopic repair and secondarily, would have worse objective and subjective outcomes.Methods:This was a retrospective chart review identifying all patients undergoing primary arthroscopic surgical stabilization for anterior shoulder instability between 2013-2019 at a single academic institution. Demographics, clinical history, physical exam, imaging, operative details, and postoperative course was reviewed. Patients were eligible for inclusion if they underwent arthroscopic Bankart repair without remplissage sustained one or two dislocation events and were clinically followed for a minimum of 12 months postoperatively. Exclusion criteria included posterior instability, multidirectional instability, and previous stabilization surgery, Primary outcome was documentation of recurrent shoulder dislocation during the postoperative period. Secondary clinical outcome measures were assessed including need for revision surgery, need for manipulation under anesthesia (MUA), range of motion, strength, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), PROMIS mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Brophy shoulder activity scores.Results:A series of 89 patients (mean age 21.3 years ± 7.3 years) met criteria for inclusion. 72 shoulders underwent surgical stabilization after a single shoulder dislocation event and 17 underwent surgery after sustaining two documented shoulder dislocations. No significant difference in demographic and radiographic characteristics, including presence of bony Bankart and off-track Hill Sachs lesions, was present between the groups. The rate of recurrent dislocation was significantly higher in the multiple dislocation group compared to single dislocations (31% vs 12%, p=0.048). There was a trend toward increased rate of revision stabilization in the 2nd dislocation group which did not reach statistical significance (22% vs 58%, p=0.167). No significant difference was present in the need for revision surgery, need for MUA, conversion to Latarjet procedure, range of motion, supraspinatus strength, VAS, PROMIS, ASES, and Brophy scores between the groups.Conclusions:Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and undergo surgical stabilization following just one additional event are at increased risk of failure following surgery. Furthermore, patients who have sustained even one additional dislocation from the primary event may benefit from more aggressive approaches may be necessary including arthroscopic approaches with augmentation or open approaches. Despite differences in recurrence rates, both groups achieved excellent subjective functional outcomes at a minimum of 12 months after surgery.

Comparison of efficacy of intra articular steroid injection versus manipulation under anesthesia (MUA) in idiopathic frozen Shoulder.

Objective: To compare efficacy of intra-articular steroid (IAS) injection with manipulation under anesthesia (MUA) in idiopathic FS. Study Design: Randomized Control Trail. Setting: Department of Orthopedic, Independent University Hospital, (IMC) Faisalabad. Period: 1st January 2021 to 30th June 2021. Material &amp; Methods: Diagnosis of FS was based upon detailed history and proper physical. Group A (n=50) included intra-articular injection patients and Group B (n=50) was patients receiving MUA. Pain was measured by VAS and disability was measured by Disability Index (SPADI) scale. Results: Mean age of sample was 37 ± 10.52 in group A and 39.14± 9.48 in group B. Age of patients ranges from 35 to 50 years. Female patients were greater in both the groups. Most of the patients have duration of disease for more than 1 month. The ratio of patients with right side disease was more than 50% in both the groups as compared to left side. In group A. there was a significant decrease in mean pain from 3.45 ± 1.12 to 2.16 ± 0.8 In group B, mean pain score decreased from 3.65 ± 0.88 to 2.35 ± 0.68 1. Overall group A was more effective as compared to group B but the results were not significant statistically. Conclusion: The intra-articular injection method was superior to MUA because it was easier, safer, and less expensive, and it produced early results.

Risk of Postoperative Stiffness Following Multiligamentous Knee Injury Surgery Is Not Affected by Obesity: A Multicenter Study

The purpose of this study was to examine the relationship between obesity and postoperative stiffness following surgical management of multiligamentous knee injuries (MLKIs) using a large two-center cohort, by both 1) using binary cutoffs at various body mass indexes (BMIs) and 2) a linear regression model. 190 consecutive patients who underwent surgical management of MLKIs between January 2001 and March 2020 were reviewed at two level 1 academic trauma centers. Patient demographics, surgical characteristics, and manipulation under anesthesia (MUA)/lysis of adhesions (LOA) were reviewed. Patients were stratified by obesity grades: grade 1 (BMI 30 to <35) grade 2 (BMI 35 to <40); grade 3 (BMI >40), and compared with a nonobese comparison group with BMI <30. Multivariate logistic regressions were performed, including the covariates of age, gender, BMI, acute versus chronic injury, external fixator, vascular injury, knee dislocation, and Schenck Classification. Fisher's exact test was used to compare rate of MUA between grades of obesity. Analyses were performed with R. Statistical significance was set at P < .05. The mean BMI of the cohort was 29.2 kg/m2. The mean overall follow-up was 27.2 ± 7.2 months (range: 14-142 months). There were 55 (29.1%) MUA procedures observed at a mean 3.77 ± 2.18 months (range: 1.8-9.7 months) after final MLKI surgery. No significant difference was found in BMI of patients who underwent a MUA compared to patients who did not (30.2 vs 28.8; P= .67). There was no significant difference in rate or time to MUA following MLKI surgery between groups, with logistic regression demonstrating no significance (P= .144). Use of external fixation at the index surgery (OR= 3.3 [95% CI: 2.2, 4.7; P < .0001]) and vascular injury (OR= 6.2 [95% CI: 1.8, 24.5; P= .005]) were found to be independent predictors for need for MUA. No difference in risk for postoperative stiffness requiring MUA following surgery for MLKI was found based on BMI. At all BMI levels, there were no significant increase in need for postoperative MUA, suggesting at minimum a neutralizing effect of obesity on postoperative stiffness. In addition, patients with external fixator use and vascular injury at index surgery were found to be at significantly higher risk for postoperative stiffness requiring MUA following surgery for MLKI. Surgeons should be aware of the risk factors for arthrofibrosis when proceeding with surgical repair or reconstruction of two or more ligaments of the knee. III, multicenter retrospective cohort study.

Manipulation under anesthesia after total knee arthroplasty: a retrospective study of 145 patients.

Background and purposeManipulation under anesthesia (MUA) is considered to be effective in treating stiffness after total knee arthroplasty (TKA). However, not all patients achieve a satisfactory range of motion (ROM) after MUA. This retrospective study determined the outcome of MUA and identified the factors affecting it.Patients and methodsThe final sample consisted of 150 MUAs performed on 145 patients. The parameters of interest were ROM and Knee Society Score (KSS) or Oxford Knee Score (OKS). The associations of preoperative, perioperative, and postoperative risk factors with gain in flexion and flexion at post-MUA follow-up (an average of 2 months after MUA) were analyzed using multivariable regression model.ResultsThe mean of 26° (95% CI 23–29) gain in flexion and the mean of 3° (CI 2–4) gain in extension were noticed at post-MUA follow-up when compared with the ROM preceding MUA. The mean post-MUA-FU flexion was 99° (CI 97–102) and the mean post-MUA-FU extension deficit was 4° (CI 2–5). KSS (121 vs. 129) and OKS (29 vs. 28) were similar before and after MUA. The early timing of MUA was associated with better gain in flexion –0.04 (CI –0.08 to –0.01), while we found no association between the timing of MUA and flexion after MUA –0.004 (CI –0.03 to 0.03). High BMI was associated with better gain in flexion 0.8 (CI 0.2–1.5).InterpretationWe found that ROM improved substantially after MUA. The gain in flexion decreased as the time between TKA and MUA increased.

Irreducible lateral knee dislocation in an 88 year old female: A case report

We present the unique case of a 88-year-old female who suffered a lateral knee dislocation of the right knee following a fall on a wet bathroom floor. Attempts at realignment via manipulation under anaesthesia (MUA) were unsuccessful, so the patient underwent an open reduction and the application of an external fixator to stabilise the knee. Knee dislocations are characterised by a high rate of neurovascular injuries, therefore special emphasis should be made on the prompt diagnosis and treatment of such injuries. Informed consent was obtained from the patient and family for the publication of the case report and all the figures included.

Manipulation Under Anesthesia Is Associated With an Increased Rate of Early Total Knee Arthroplasty Revision.

Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) frequently has been used as a first-line treatment to restore functional range of motion after unsuccessful physical therapy. Although there are studies reporting that MUA assisted in restoring range of motion, there is a paucity of literature on the influence of MUA on the risk of revision TKA. The goal of our study was to determine whether MUA was associated with an increase in the rate of revision TKA within 2 years of MUA. A total of 49,310 patients within a single institution who underwent primary TKA were identified from 1999 to 2019. Data were matched at a 1:3 ratio (TKA with and without MUA, respectively) based on age, sex, and body mass index. A matched comparison cohort was conducted, with the MUA cohort having 575 patients and the no MUA cohort having 1725 patients. A statistically significant increase in the rate of noninfectious etiology revision TKA was found in the MUA cohort (7.3%) compared with the no MUA cohort (4.9%; P=.034). The most common reason for revision TKA after MUA was persistent stiffness, including arthrofibrosis and ankylosis; however, aseptic loosening, ligamentous instability, and periprosthetic fracture were found to be responsible for 21.4% of revision TKA procedures. Although MUA is a commonly performed procedure for treating stiffness after primary TKA, the orthopedic surgeon should counsel patients on the association of increased rate of revision TKA after MUA, most commonly, persistent stiffness. [Orthopedics. 2022;45(5):270-275.].

Role of non-ASA VTE prophylaxis in risk for manipulation following primary total knee arthroplasty.

Stiffness and decreased range of motion frequently lead to hindrance of activities of daily living and dissatisfaction follow total knee arthroplasty (TKA). This study aims to evaluate the effect of non-aspirin (ASA) chemoprophylaxis and determine patient-related risk factors for stiffness and need for manipulation under anesthesia (MUA) following primary TKA. A review of all patients undergoing primary TKA from 2013 to 2019 at a single academic orthopedic hospital was conducted. The primary outcome measure was MUA performed post-operatively. Chi-square analysis and Mann-Whitney U test were used to determine statistically significant relationships between risk factors and outcomes. Significance was set at p < 0.05. Univariate logistic regression was performed to control for identified independent risk factors for MUA. A total of 11,550 patients undergoing primary TKA from January 2013 to September 2019 at an academic medical center were included in the study. Increasing age and Charlson Comorbidity Index were associated with statistically significant decreased odds of MUA (0.93, 95% CI: 0.92-0.94, p < 0.001, OR 0.71, 95% CI 0.63-0.79, p < 0.001). Active smokers had a 2.01 increased odds of MUA (OR 2.01, 95% CI 1.28, 3.02, p < 0.001). There was no significant difference in rates of MUA between ASA and non-ASA VTE prophylaxis (p 0.108). Younger age, lower CCI, and history of smoking are associated with a higher rate, while different chemical VTE prophylaxis does not influence rate of MUA after TKA. Arthroplasty surgeons should consider these risk factors when counseling patient preoperatively. Understanding each patients' risk for MUA allows surgeons to appropriately set preoperative expectations and reasonable outcome goals.

Correlation Between Patient-Reported "Happiness" With Knee Range of Motion and Objective Measurements in Primary Knee Arthroplasty.

The purpose of this study was to evaluate the correlation between objective knee range of motion (ROM) and patient "happiness" with knee ROM after total knee arthroplasty. This was a retrospective review of all primary total knee arthroplasties from June through December 2019, yielding 902 patients (1,009 knees). Records were reviewed for knee ROM preoperatively and postoperatively at 6-week follow-up as well as whether patients self-reported being "Happy with their ROM" (HWROM). Clinical records were reviewed for documents ROM as well as manipulation under anesthesia (MUA). The mean preoperative ROM was 110 ± 16 degrees, and 40% of patients were happy with their ROM. Postoperatively, the mean ROM was 106 ± 13 degrees (P < .001), and 76% of patients were HWROM (P < .001). The mean change in knee ROM was (-) 5 ± 17 degrees. The mean postoperative ROM and change in ROM of patients who were HWROM after surgery were 109 ± 12 degrees and (-)2 ± 16 degrees. In patients not HWROM postoperatively, the mean ROM and change in ROM were 98 ± 14 degrees and (-)12 ± 18 degrees (P < .001). Patients with a lower preoperative ROM were statistically significantly more likely to have a positive change in their HWROM (f ratio= 41, P < .001). MUAs were performed in 7.2% of knees, and 28% of patients who underwent an MUA were HWROM before MUA. Early postoperative knee ROM was correlated with patient HWROM. However, further longer term follow-up and more detailed analysis of patient happiness with ROM are needed.

Optimising the use of physiotherapy resources after manipulation under anaesthetic for frozen shoulder.

Manipulation under anaesthetic (MUA) is a successful treatment for frozen shoulder (FS), and the recovery period and recurrence rates may be reduced by postoperative physiotherapy. This study evaluates two physiotherapy pathways for patients undergoing MUA for FS. Between 2016 and 2018, 248 age- and sex-matched patients presented to either a NHS secondary care upper limb service or the lead author's independent practice with a diagnosis of FS. The patients had differential access to postprocedure physiotherapy based on which service they presented to. In Group1, physiotherapy advice only was given to the patient. In Group2, supervised hydrotherapy and physiotherapy occurred postoperatively. Pre- and postprocedure Oxford Shoulder Scores (OSS) were collected for each group. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on postoperative OSS. Group2 showed a significantly greater improvement in postprocedure OSS when compared with Group 1 (18.2 vs 16.7) p<0.001). The estimated maximum effect of physiotherapy on postoperative OSS was an increase of 3.2. Following MUA for FS, a statistically significant increase in OSS was detected in patients receiving postprocedure physiotherapy compared with advice alone. There was no difference in recurrence rates. The increase in OSS (3.2) is below the minimal clinically important difference, raising questions regarding the relative importance of postprocedure physiotherapy in a resource-limited environment.

Aspirin Administered for Venous Thromboembolism Prophylaxis May Protect Against Stiffness Following Total Knee Arthroplasty.

Aspirin has become the main agent for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). This study assessed whether aspirin is associated with less knee stiffness compared to warfarin and other chemoprophylaxis agents. This is a retrospective review of all primary and revision TKAs performed between January 2009 and October 2020 at a high volume institution. Demographics, comorbidity data, and operative variables were extracted from medical records. VTE prophylaxis administered during this time period included aspirin, warfarin, and "others" (factor Xa, unfractionated heparin, low-molecular-weight heparin, fondaparinux, adenosine diphosphate receptor inhibitor, and direct thrombin inhibitor). The primary outcome assessed was manipulation under anesthesia (MUA) performed within 6 months of index surgery. Secondary outcome included major bleeding events. Univariate followed by multivariate regression analyses were performed. A total of 15,903 cases were included in the study, of which 531 (3.3%) patients developed stiffness that required MUA. The rates of MUA were 2.7% (251/9223) for patients receiving aspirin, 4.2% (238/5709) for patients receiving warfarin, and 4.3% (42/971) for all others (P's < .001). Multivariate regression analysis confirmed that aspirin is associated with lower rates of VTE compared to warfarin (adjusted odds ratio 1.423, 95% confidence interval 1.158-1.747, P < .001) and compared to other anticoagulation medications (adjusted odds ratio 1.742, 95% confidence interval 1.122-2.704, P= .013). Major bleeding events were also significantly lower in patients who received aspirin compared to the other 2 groups (P's= .001). Aspirin prophylaxis is associated with lower rates of MUA following TKA compared to warfarin and other VTE chemoprophylactic agents when grouped together.